Name* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address* Best Date & Time to Be Reached*Cell Phone*Home Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Occupation*Hrs of Work Per Week*CHECK OFF WHICH OF THE FOLLOWING OCCURED AT LEAST ONCE IN THE PAST 30 DAYSKnee Pain R L Knee Decreased Motion R L Knee Swelling R L Shoulder Pain R L Shoulder Decreased Motion R L Shoulder Swelling R L Hip Pain R L Hip Decreased Motion R L Hip Swelling R L Ankle Pain R L Ankle Decreased Motion R L Ankle Swelling R L Elbow Pain R L Elbow Decreased Motion R L Elbow Swelling R L Back Pain R L Back Decreased Motion R L Back Swelling R L Neck Pain R L Neck Decreased Motion R L Neck Swelling R L Wrist Pain R L Wrist Decreased Motion R L Wrist Swelling R L Hand Pain R L Hand Decreased Motion R L Hand Swelling R L Other Problems Overweight Diabetes Digestive Problems Dizziness Fatigue Balance Problems Neuropathy Sleep Problems OtherWhich health problem bothers you the most?*On a scale of 1 - 10, at it's worst, how bad does it get? (1 = low, 10 = high)*Please enter a number from 1 to 10.How often does it bother you?*How long have you had the problem?*What could you do before this problem you cannot do now?*HOW DOES THE PROBLEM AFFECT YOU?* Moodiness/Irritability Decreased Energy Restricted Activity Burden to My Family Interferes with Exercise/Hobbies Reduced Enjoyment of Life * I would like to receive a consultation and evaluation to determine a natural solution to my problems.Best day of the week to receive an evaluation*Best time of the day to receive an evaluation*We will call to confirm your appointment.THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT. OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.